Paraspinal epidural

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

For patients with spine related pain, a paraspinal block is sometimes recommended. Paraspinal blocks fall into two categories:

• Facet joint injections
• Nerve root blocks

Facet blocks

The injection of local anesthetic and steroids into the facet joint is therapeutic. A combination of local anesthetic and steroids is injected. Long-term relief (6 months or better) can be obtained in 30-50% of patients.

Patients referred for facet injections most often have degenerative disease of the facet joints. However, even if the facet joint appears normal on x-ray, facet injections still may be of use, as synovitis (inflammation of the lining of the joint) can cause facet pain, particularly in younger patients.

Postlaminectomy syndrome, occurring after laminectomy, is also an acceptable reason to perform facet injections.

Patients with lumbar facet pain ("facet syndrome") present with back, buttock, or hip pain. The pain is worse with back extension. Nerve root type pain, leg weakness, and leg numbness are not considered part of the facet syndrome and suggest nerve root compression.

Occasionally, synovial cysts may be symptomatic. These cysts are located next to a facet joint. The injection of steroids into the associated facet joint is effective in resolving synovial cysts in 30-40% of patients, although repeated injections may be necessary.

Cervical facet pain can cause headaches, neck muscle spasms, and neck pain. This pain is typically worse when patients extend or turn their neck. In particular, the upper cervical facets can often cause occipital headaches.

Nerve root blocks

Nerve root blocks with local anesthetic and steroids are used to produce long-term relief, primarily in patients with radiculopathy.

A trained rheumatologist or orthopedic surgeon generally administer this type of injection. Ultrasound or fluoroscopic guidance is mandatory for all paraspinal or nerve root blocks.

Phospholipase A is a chemical whose production is stimulated by extruded nucleus pulposus material. It causes inflammation and pain in the adjacent nerve, even when no compression is present. Because steroids have anti-inflammatory actions, injections around the nerve root may reduce the inflammation and pain.

• After diskectomy in patients who have recurrent radiculopathy but no recurrent disk herniation, symptoms are often caused by scar tissue. Many patients can be treated successfully by using nerve root block.
• Patients with disk herniations can be helped with nerve root blocks. The pain results from an inflammation of the nerve root and not directly from the pressure of the disk. Steroid injections can reduce inflammation and pain in many patients.

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